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يم صدق هللا العظ(32سورة البقرة اآلية )

Arthroscopic Versus Open

Synovectomy In Rheumatoid

Knee

AcknowledgementAt first, thanks to ALLAH for all his gifts

Words stand short when they come to express my gratefulness to

my supervisors. I would like to express my deep gratitude and

appreciation to Prof.Dr. MOHAMMED SALAH ELDEEN SHAWKY,

Professor of Orthopedic Surgery, Faculty of Medicine, Benha University,

for his great supervision, great help, available advice, continuous

encouragement and without his support it was impossible for this

study to be achieved in this form. I had the privilege to benefit from his

great knowledge .It is an honor to work under his guidance and

supervision.

I also sincerely express my great appreciation to Prof.Dr. MAMDOUH

MOHAMMED EL-KARAMANY, Assistant Professor of orthopaedic

surgery, Faculty of Medicine, Benha University, for his advice and all

efforts he offered to make this work possible.

Next I would like to express my deep thanks and grateful

appreciation to Dr. SAMEER MOHAMAD ABDALLAH , Lecturer of

orthopaedic surgery, faculty of Medicine, Benha University for his

constant encouragement, continuous support and everlasting skillful

help. Their favors will never be forgotten.

Last but not least, I dedicate this work to my family whom without

their sincere emotional support this work could not have been

completed.

Anatomy of Synovial Joints

Synovial joints contain the following structures : Synovial cavity Articular capsule Articular cartilage* Many, but not all, synovial joints also containadditional structures:

o Articular discs or menisci

o Articular fat pads

o Bursa

o Accessory ligaments

o Tendons

Blood supply:

The blood supply of a synovial joint is derived

from the arteries sharing in the anastomosis around

the joint.

Synovial membrane and synovial fluid:

Synovial membrane is the soft tissue found

between the articular capsule and the joint cavity

of synovial joints.

Synovial membrane of the knee

Synovial fluid:

A viscous fluid found in the cavities of synovial joints. With

its yolk-like consistency. The principal role of synovial fluid

is to reduce friction between the articular cartilages of

synovial joints during movement.

Anatomy of knee joint

Pathology of R.A.

•Joints and tendons:

Stage 1 – pre-clinical :

- Raised ESR, C-reactive protein (CRP)

and RF may be detectable years before

the first diagnosis.

Stage 2 – synovitis:

- Proliferation of synoviocytes.

- There is thickening of the capsular

structures.

- Villous formation of the synovium and a

cell-rich effusion into the joints and tendon

sheaths. the disorder is potentially

reversible.

Stage 3 – destruction:

- Articular cartilage is eroded and granulation

tissue creeps over the articular surface.

- A synovial effusion, often containing copious

amounts of fibrinoid material, produces

swelling of the joints, tendons and bursae.

Stage 4 – deformity:

- The combination of articular destruction,

capsular stretching and tendon rupture leads to

progressive instability and deformity of the

joints.

• Extra-articular tissues:

Rheumatoid nodules:

Nodules occur under the skin (especially over

bony prominences), in the synovium, on

tendons, in the sclera and in many of the

viscera.

Diagnosis- X-rays :

There may be no changes in the early stages of the

disease.

The x-ray may demonstrate juxta-articular osteopenia

There may be bony erosions and subluxation.

- MRI :MRI has proved itself as a valuable technique to detect

changes in all components of the joints affected by RA.

Synovitis volume, bone marrow edema and bone erosions

are suitable for serial measurement.

- Ultrasonography:

It is more sensitive in detecting synovial and tendon

inflammation than clinical examination alone

Management:Treatment Goals:

The ultimate treatment goal is remission and complete

suppression of disease activity.

Other treatment goals which include control synovitis,

Relieve Pain, maintain functional ability, improve and

maintain quality of life and minimize adverse events,

particularly from pharmacological therapy.

Cost effective treatment:There is no cure for RA, but treatments can improve

symptoms and slow the progress of the disease.

Surgical Treatment

Aims of surgical treatment options:- Diagnosis by taking arthroscopic synovial biopsy as part of

arthroscopic treatment.

- Debulking the diseased tissues as synovectomy can be

performed both arthroscopically and open

- Regaining motion by Capsulectomy, removal of secondary

spurs and resurfacing.

- Pain relief is done through synovectomy and joint resurfacing.

- In early phases of the disease, an arthroscopic or open

synovectomy may be performed. It consists of the removal of

the inflamed synovium and prevents a quick destruction of the

affected joints.

- Severely affected joints may require joint replacement surgery.

Synovectomy of the knee

- Synovectomy is the surgical removal of a part of the

synovial membrane of a synovial joint.

- Surgical synovectomy is recommended for patients who do

not experience substantial pain relief in response to medical

therapy for 6 months.

- During synovectomy, part of the synovium is left intact so

that it can still perform its function of releasing synovial fluid,

which serves as a lubricant in the joint.

- Synovectomy can be performed by making a large incision

that exposes the entire joint or it can be done using

arthroscopic methods.

- The choice of approach depends on the extent of repair

required.

Knee Synovectomy Indications

It is indicated generally in chronic synovitis. The indication

remains the same weather the synovectomy performed

arthroscopically or by open surgery.

Synovectomy should be performed when the disease is

limited to the synovium before the involvement of articular

cartilage and bone and when there has been a failure of trial of

adequate conservative treatment for at least 6 months.

Knee Synovectomy Contraindications

- Advanced arthritis.

- Extensive joint instability with bone destruction.

Knee Synovectomy Complications

Iatrogenic chondral injury.

Hemoarthrosis.

DVT and Pulmonary embolism.

Stiffness.

Infection.

Fluid Extravasation and Compartment Syndrome.

Instrument failure and breakage.

Arthrofibrosis, Patella infra and Loss of motion.

Ligament Injuries.

Fractures.

Synovitis and synovial fistula.

Neurovascular injuries.

Results of Synovectomy in Rheumatoid knee

- The immediate :

Operative removal of synovial membrane from the knee

in rheumatoid arthritis will give immediate pain relief in some

two-thirds of patients.

- Short term results :

The success of the operation is measured by the loss of

pain, swelling of pain, range of motion achieved, stability and

strength of quadriceps muscle.

- Long term results:

The patients were initially seen at intervals of six

months and later at yearly intervals depending on their

condition. the continuing success of a synovectomy can be

judged from the way the joint reacts during a general flare-up

of the disease involving several joints.

Open surgical synovectomy

Indications:

Persistent pain and swelling of the knee despite adequate

medical treatment for a minimum of six to twelve months.

Contraindications:

- End-stages with signs of bony destruction.

- Deformity and instability of the joint.

- The stiff, dry, painful joint.

- A flexion contracture greater than 25 degree.

Advantages:

- The major advantage of this procedure is that with the

open operation one is confident that nearly all the synovium

has been removed.

- In late stage disease open operation is preferable as it

allows removal of the menisci as well as the proliferative

synovium from the articular margins of the tibia.

- General debridement of the joint with trimming of

osteophytes and removal of pannus can also be readily

achieved.

- Open knee synovectomy is standard and allows an

inspection of all compartments.

Disadvantages:

- In open procedure the posterior compartment was not

approachable due to proximity to neurovascular structures

and the synovium present in intercondylar notch and

under and over the meniscus was difficult to take out and

so it never became total synovectomy.

- With open synovectomy there is a significant morbidity

such as knee stiffness due to arthrofibrosis.

- The other major problem with the open operation is the

length of postoperative rehabilitation as patient usually

needs to be an in-patient for up to 14 days and requires

regular physiotherapy for up to three months before gaining

maximal restoration of function.

Approach

An anterior skin incision is made utilizing either a straight

mid-line or a medial Para patellar incision is made round the

upper medial border of the patella.

- The synovim is excised by block

dissection from medial, lateral and

anterior aspects of the joint.

- The pathological tissues are

removed from the medial and lateral

aspects of femoral condyles.

( A ) quadriceps snip.

( B ) a straight mid-line

incision.

( C ) medial Para patellar

incision.

( D ) mid-vastus incision .

Post-operative:- A compression bandage is applied to the knee, with

maximum pressure over the site of the pouch. This bandage is

left on for one or two days. It is then replaced by a light elastic

bandage, and active exercises, consisting of raising the

extended leg and flexion exercises.

- After a week the patient is allowed to get up.

- Rehabilitation is started under physiotherapist supervision

after two weeks.

- The range of motion of operated knee is monitored .It was

recorded that the knee motion regained after 3 to 6 months.

- Return to Work:

Limited work loading of the affected joint is an appropriate

restriction. This may include no lifting, carrying, twisting,

pushing or pulling, standing, squatting, or kneeling, depending

on the joint involved.

Individuals may be required to use devices to assist with

ambulation such as crutches, canes, or walkers.

Possible complications of surgery

- Accidental damage to the knee joint.

- Bleeding.

- Nerve damage.

- Deep Vein Thrombosis.

- Pulmonary embolism.

- Persistent or recurrent pain.

- Scar formation and adhesions.

Arthroscopic synovectomy

Indication of knee arthroscopy:

After conservative modalities have proven ineffective over a

reasonable period of time and the individual remains

disabled, consideration for an arthroscopic evaluation of the

knee is warranted for purposes of diagnosis and treatment.

Patient education plays a critical role in the outcome of

arthroscopic surgery.

Contraindication:

- Unsatisfactory skin conditions and history of knee reflex

sympathetic dystrophy.

- End-stages with signs of bony destruction.

- Deformity and instability of the joint.

Advantages of arthroscopic synovectomy

Arthroscopic synovectomy is a surgical procedure with

minimal morbidity, which does not require open arthrotomy,

and leaves less joint capsule and ligament damage, thus

allowing immediate mobilization and reducing hospital stays.

As compared with open arthrotomy, the arthroscopic

technique offers superior views, easier access to knee

compartments and facilitates the effective removal of

pathologic synovium.

Incision is minimal, Quadriceps muscle remains intact,

Incidence of infection is decreased, Incidence of hemarthrosis

is decreased, Range of motion is maintained or increased.

Postoperative physical therapy is minimal or none. Menisci

are spared. Patient acceptance is high.

Operative Technique

Arthroscope insertion:

- Extend the knee and make a small stab wound superior

and medial to the patellar tendon. Introduce the inflow

cannula into the joint utilizing the blunt obturator.

- Flex the knee. Identify the “soft spot” for the inferior

lateral portal. Introduce the cannula for the arthroscope

through this portal.

- Insert the arthroscope into the knee joint through the

cannula. Extend the knee and position the arthroscope in

the suprapatellar pouch.

- Inspect the patellofemoral joint.

- Inspect the lateral gutter.

- Inspect the medial gutter.

- Inspect the lateral compartment

Postoperative Care Issues

A compressive dressing should be placed at the end of

surgery and is normally removed approximately 48 hours

after the procedure.

The stitches will be removed at clinic if the patient is seen 2

weeks or less post operatively.

patients can weight-bear as tolerated after surgery.

Range-of-motion and strengthening exercises can be

initiated immediately after the procedure.

Most patients can successfully rehabilitate with a home

exercise program.

The patients began physical therapy the same day to

achieve maximum range of motion, strengthen the

quadriceps and hamstring muscles, and use modalities to

decrease the swelling, pain, and inflammation in the acute

postoperative period.

Complications: Infection.

Nerve injury.

Vessel injury.

Tourniquet palsy.

Bleeding.

Persistent or recurrent pain.

Knee ligament injury.

Broken instruments.

Synovial fistula.

Equipment failure.

Common Occurrences: Some patients will note bruising around the knee.

Anterior knee pain.

Persistence of arthritic symptoms.

Portal discomfort.

Swelling.

Skin itching.

Return to work:

If patients’ job involves sitting for the majority of the day

they can return after 3 days.

If their job is physically demanding and involves heavy

manual work or standing for long periods, 1-2 weeks off

work may be necessary.

Driving:

Patients should not return to driving until their knee is pain

free and they have full knee flexion.

Summary and Conclusion

• surgical synovectomy is recommended for patients who do

not experience substantial pain relief in response to medical

therapy for 6 months.

• When there is structural damage to a joint or the tissues

around it, medicines can't fix it, and surgery may help.

• In early phases of the disease, an arthroscopic or open

synovectomy may be performed. It consists of the removal

of the inflamed synovia and prevents a quick destruction of

the affected joints.

• Although there has been an increase in the popularity of

less invasive methods of synovectomy such a radiation

synovectomy and arthroscopic synovectomy ,the open

synovectomy remains the procedure of choice in the

management of sever synovitis of the knee joint even quite

late in the disease process .

• The major advantage of open synovectomy is that with the

open operation one is confident that nearly all the synovium

has been removed.

• With open synovectomy there is a significant morbidity such

as knee stiffness due to arthrofibrosis and, rarely, wound

and joint infection. The other major problem with the open

operation is the length of postoperative rehabilitation .

• Arthroscopic synovectomy offers several theoretical

advantages, including decreased invasiveness of surgery,

potential for faster recovery, and reduced hospital stay.

• Patients undergoing arthroscopic synovectomy had similar

pain reduction, but more frequent recurrences of synovitis

than patients with open synovectomy.

• After open synovectomy range of motion of operated knee is

monitored .It was recorded that the knee motion regained

after 3 to 6 months.

• After arthroscopic synovectomy range of motion regained

quickly as the approach minimally invasive with no affection

of muscles and no adhesions.